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Deficiency Records for Saint Joseph Transitional Rehabilitation Center
A list of the most recent deficiencies for Saint Joseph Transitional Rehabilitation 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 Saint Joseph Transitional Rehabilitation 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-09-18 | 2024-11-12 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2024-09-18 | 2024-11-12 | 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 | 2024-09-19 | 2024-10-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-09-19 | 2024-10-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-09-19 | 2024-10-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-19 | 2024-10-29 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-09-19 | 2024-10-15 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2024-09-19 | 2024-10-04 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-09-22 | 2023-10-31 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-09-22 | 2023-10-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-22 | 2023-10-31 | 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 | 2023-09-22 | 2023-10-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-22 | 2023-10-31 | 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 | 2023-09-22 | 2023-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-22 | 2023-10-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-22 | 2023-10-31 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-09-22 | 2023-10-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-09-22 | 2023-10-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-09-22 | 2023-10-31 | 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 | 2023-09-22 | 2023-10-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-22 | 2023-10-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-09-22 | 2023-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-22 | 2023-10-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-22 | 2023-10-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-09-22 | 2023-10-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-22 | 2023-10-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-22 | 2023-10-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-09-22 | 2023-10-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-28 | 2023-01-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-12 | 2022-10-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-12 | 2022-10-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-12 | 2022-10-18 | Y |
| 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 | 2022-08-12 | 2022-10-18 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-08-12 | 2022-10-18 | 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 | 2022-08-12 | 2022-10-18 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-08-12 | 2022-10-18 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-08-12 | 2022-10-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-12 | 2022-10-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-12 | 2022-10-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-12 | 2022-10-18 | 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 | 2022-08-12 | 2022-10-18 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-08-12 | 2022-10-18 | 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 | 2022-08-12 | 2022-10-18 | 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 | 2022-08-12 | 2022-10-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-12 | 2022-10-18 | Y |
| Provide appropriate foot care. | Health | 2022-08-12 | 2022-10-18 | 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 | 2022-08-12 | 2022-10-18 | Y |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-08-11 | 2022-09-26 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-08-11 | 2022-09-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-11 | 2022-09-23 | 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 | 2022-08-11 | 2022-09-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-11 | 2022-09-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-11 | 2022-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-11 | 2022-09-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-11 | 2022-09-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-08-11 | 2022-09-16 | 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 | 2022-08-11 | 2022-09-14 | N |
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