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Deficiency Records for Josephine Caring Community
A list of the most recent deficiencies for Josephine Caring Community. 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 Josephine Caring Community. 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? |
|---|---|---|---|---|
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-09 | 2024-09-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-15 | 2024-08-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-15 | 2024-08-20 | 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 | 2024-07-15 | 2024-08-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-15 | 2024-08-20 | 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 | 2024-07-15 | 2024-08-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-15 | 2024-08-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-15 | 2024-08-20 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-07-09 | 2024-08-12 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-07-09 | 2024-08-02 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-07-09 | 2024-08-02 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-07-09 | 2024-08-02 | N |
| Establish methods for sharing information. | Fire Safety | 2024-07-09 | 2024-08-02 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-07-09 | 2024-08-02 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-07-09 | 2024-08-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-07-09 | 2024-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-09 | 2024-08-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-07-09 | 2024-08-02 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-07-09 | 2024-08-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-07-09 | 2024-07-31 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-07-09 | 2024-07-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-09 | 2024-07-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-07-09 | 2024-07-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-25 | 2023-06-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-25 | 2023-06-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-25 | 2023-06-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-25 | 2023-06-05 | 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 | 2023-04-25 | 2023-06-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-25 | 2023-06-05 | 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 | 2023-04-25 | 2023-06-05 | 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 | 2023-04-25 | 2023-06-05 | 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 | 2023-04-25 | 2023-06-05 | N |
| Provide or obtain dental services for each resident. | Health | 2023-04-25 | 2023-06-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-25 | 2023-06-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-25 | 2023-06-05 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-04-19 | 2023-05-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-04-19 | 2023-05-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-19 | 2023-05-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-19 | 2023-05-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-19 | 2023-05-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-19 | 2023-05-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-19 | 2023-05-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-19 | 2023-05-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-19 | 2023-05-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-19 | 2023-05-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-04-19 | 2023-05-15 | N |
| Respond appropriately to all alleged violations. | Health | 2023-02-06 | 2023-03-15 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-02-06 | 2023-03-15 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-02-06 | 2023-03-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-19 | 2022-10-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-19 | 2022-10-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-14 | 2022-04-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-17 | 2019-06-13 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-05-17 | 2019-06-13 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-05-17 | 2019-06-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-17 | 2019-06-13 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-05-17 | 2019-06-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-05-17 | 2019-06-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-17 | 2019-06-13 | 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 | 2019-05-17 | 2019-06-13 | N |
| Provide activities to meet all resident's needs. | Health | 2019-05-17 | 2019-06-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-17 | 2019-06-13 | 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 | 2019-05-17 | 2019-06-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-17 | 2019-06-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-17 | 2019-06-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-17 | 2019-06-13 | 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 | 2019-05-17 | 2019-06-13 | 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 | 2019-05-17 | 2019-06-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-05-17 | 2019-06-13 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-05-08 | 2019-06-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-05-08 | 2019-06-04 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-05-08 | 2019-06-04 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-05-08 | 2019-06-04 | N |
| Establish methods for sharing information. | Fire Safety | 2019-05-08 | 2019-06-04 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-05-08 | 2019-06-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-08 | 2019-06-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-08 | 2019-06-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-05-08 | 2019-06-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-08 | 2019-06-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-08 | 2019-06-04 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-05-08 | 2019-06-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-08 | 2019-06-04 | N |
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