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Deficiency Records for All Saint's Subacute and Transitional Care

A list of the most recent deficiencies for All Saint's Subacute and Transitional Care. 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 All Saint's Subacute and Transitional Care. 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 approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-07-16 2024-08-13 N
Properly provide smoke detection systems in areas open to corridors. Fire Safety 2024-07-16 2024-08-13 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-07-16 2024-08-13 N
Provide a written emergency evacuation plan. Fire Safety 2024-07-16 2024-08-13 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-07-12 2024-07-23 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2024-07-12 2024-07-23 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-07-12 2024-07-23 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2024-07-12 2024-07-23 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 2024-07-12 2024-07-23 N
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Health 2024-07-12 2024-07-23 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-07-12 2024-07-23 N
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2024-07-12 2024-07-23 N
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Health 2023-09-29 2023-10-30 Y
Provide and implement an infection prevention and control program. Health 2023-08-03 2023-08-22 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-05-17 2023-05-17 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-05-25 2022-06-28 N
Conduct testing and exercise requirements. Fire Safety 2022-05-25 2022-06-28 N
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. Fire Safety 2022-05-25 2022-06-28 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2022-05-25 2022-06-28 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2022-05-25 2022-06-28 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-05-25 2022-06-28 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-05-25 2022-06-28 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2022-05-25 2022-06-28 N
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. Fire Safety 2022-05-25 2022-06-28 N
Meet requirements for the use of electrical equipment. Fire Safety 2022-05-25 2022-06-28 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2022-05-19 2022-06-14 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-05-19 2022-06-14 N
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2022-05-19 2022-06-14 N
Provide and implement an infection prevention and control program. Health 2021-10-20 2021-11-15 Y
Conduct testing and exercise requirements. Fire Safety 2020-01-09 2020-01-29 N
Use approved construction type or materials. Fire Safety 2020-01-09 2020-01-29 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 2020-01-09 2020-01-29 N
Provide properly protected cooking facilities. Fire Safety 2020-01-09 2020-01-29 N
Have properly installed hallway dispensers for alcohol-based hand rub. Fire Safety 2020-01-09 2020-01-29 N
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. Fire Safety 2020-01-09 2020-01-29 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2020-01-09 2020-01-29 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2020-01-09 2020-01-29 N
Properly provide smoke detection systems in areas open to corridors. Fire Safety 2020-01-09 2020-01-29 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2020-01-09 2020-01-29 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2020-01-09 2020-01-29 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2020-01-09 2020-01-29 N
Install corridor and hallway doors that block smoke. Fire Safety 2020-01-09 2020-01-29 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2020-01-09 2020-01-29 N
Have simulated fire drills held at unexpected times. Fire Safety 2020-01-09 2020-01-29 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2020-01-09 2020-01-29 N
Ensure medical gas and vacuum systems have documented maintenance programs. Fire Safety 2020-01-09 2020-01-29 N
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. Fire Safety 2020-01-09 2020-01-29 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2020-01-09 2020-01-29 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2019-11-21 2019-12-09 N
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2019-11-21 2019-12-09 N

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