St Joseph Manor Health & Rehabilitation

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Nutrition and Dietary Deficiencies

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Pharmacy Service Deficiencies

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.

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Nursing and Physician Services Deficiencies

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Give residents a notice of rights, rules, services and charges.

Resident Rights Deficiencies

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.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

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.

Pharmacy Service Deficiencies

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.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Nutrition and Dietary Deficiencies

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Services Deficiencies

Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Nutrition and Dietary Deficiencies

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

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.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

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.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Environmental Deficiencies

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Egress Deficiencies

Have exits that are accessible at all times.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

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.

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

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.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.