Inspection Results » St Joseph's Ministries

Health Inspection on April 4, 2018 ^[1]

1. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • 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. (Corrected 2018-05-14)

2. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2018-05-14)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-05-14)
   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2018-05-14)
   • Ensure each residentÂ’s drug regimen must be free from unnecessary drugs. (Corrected 2018-05-14)
   • 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. (Corrected 2018-05-14)
   • 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. (Corrected 2018-05-14)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-05-14)
   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2018-05-14)

3. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Ensure each resident receives an accurate assessment. (Corrected 2018-05-14)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-05-14)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-05-14)
   • Provide timely, quality laboratory services/tests to meet the needs of residents. (Corrected 2018-05-14)
   • 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 ne (Corrected 2018-05-14)
   • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2018-05-14)

4. Widespread: No actual harm with potential for minimal harm

   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2018-05-14)
   • Notify the resident or the residentÂ’s representative in writing how long the nursing home will hold the residentÂ’s bed in cases of transfer to a hospital or therapeutic leave. (Corrected 2018-05-14)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-05-14)