St Vincent's - a Prospera Community

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.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Nutrition and Dietary Deficiencies

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

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

Have a plan that describes the process for conducting QAPI and QAA activities.

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.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Resident Rights Deficiencies

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

Resident Rights Deficiencies

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

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 Assessment and Care Planning Deficiencies

Assess the resident when there is a significant change in condition

Resident Assessment and Care Planning Deficiencies

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

Quality of Life and Care Deficiencies

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

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.

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

Provide and implement an infection prevention and control program.

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Quality of Life and Care Deficiencies

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

Construction Deficiencies

Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

Quality of Life and Care Deficiencies

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

Nutrition and Dietary Deficiencies

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

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

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.

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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.

Quality of Life and Care Deficiencies

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

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.

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

Have proper medical gas storage and administration areas.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

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

Smoke Deficiencies

Provide properly protected cooking facilities.