A list of the most recent deficiencies for St Michael's Healthcare. 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? |
|---|---|---|---|---|
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-22 | 2023-10-21 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-15 | 2023-01-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-15 | 2023-01-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-15 | 2023-01-14 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-12-15 | 2023-01-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-15 | 2023-01-14 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-12-15 | 2023-01-14 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2022-12-15 | 2023-01-14 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2022-12-15 | 2023-01-14 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2022-12-15 | 2023-01-14 | N |
| 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. | Health | 2022-12-15 | 2023-01-14 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-12-15 | 2023-01-14 | Y |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-12-13 | 2023-01-14 | N |
| 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. | Health | 2022-07-22 | 2022-08-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-02 | 2021-08-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-02 | 2021-08-01 | N |
| 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. | Health | 2021-07-02 | 2021-08-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-02 | 2021-08-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-07-02 | 2021-08-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-07-02 | 2021-08-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-07-02 | 2021-08-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-02 | 2021-08-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-07-02 | 2021-08-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-02 | 2021-08-01 | N |
| Provide activities to meet all resident's needs. | Health | 2021-07-02 | 2021-08-01 | 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 | 2021-07-02 | 2021-08-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-02 | 2021-08-01 | N |
| 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. | Health | 2021-07-02 | 2021-08-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-02 | 2021-08-01 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-07-02 | 2021-08-01 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-07-02 | 2021-08-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-02 | 2021-08-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-02 | 2021-08-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-02 | 2021-08-01 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-07-02 | 2021-08-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-06-28 | 2021-08-01 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-06-28 | 2021-08-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-28 | 2021-08-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-28 | 2021-08-01 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-06-28 | 2021-08-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-01-10 | 2020-02-03 | 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 | 2020-01-10 | 2020-02-03 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-01-10 | 2020-02-03 | N |
| Assess the resident when there is a significant change in condition | Health | 2020-01-10 | 2020-02-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-10 | 2020-02-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-10 | 2020-02-03 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2020-01-10 | 2020-02-03 | 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 | 2020-01-10 | 2020-02-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-10 | 2020-02-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-01-10 | 2020-02-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-10 | 2020-02-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-10 | 2020-02-03 | 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 | 2020-01-10 | 2020-02-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-01-10 | 2020-02-03 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2020-01-10 | 2020-02-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-10 | 2020-02-03 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2020-01-10 | 2020-01-10 | N |
