A list of the most recent deficiencies for St Anthony's Nsg and Rehab Ctr. 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? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-01-02 | 2024-02-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-02 | 2024-02-09 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-02 | 2024-02-09 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-01-02 | 2024-01-29 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-10-31 | 2023-12-06 | 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 | 2023-10-31 | 2023-11-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-31 | 2023-11-24 | Y |
| 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 | 2023-10-31 | 2023-11-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-18 | 2023-11-10 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-07-03 | 2023-07-20 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-07-03 | 2023-07-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-31 | 2023-04-02 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-31 | 2023-04-02 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-08 | 2023-03-27 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-03-08 | 2023-03-27 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-19 | 2023-02-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-19 | 2023-01-30 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-12-19 | 2023-01-18 | 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 | 2022-12-19 | 2023-01-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-19 | 2023-01-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-19 | 2023-01-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-12-19 | 2023-01-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-19 | 2023-01-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-19 | 2023-01-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-19 | 2023-01-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-12-19 | 2023-01-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-19 | 2023-01-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-19 | 2023-01-18 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-12-16 | 2023-01-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-16 | 2023-01-13 | N |
| 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. | Health | 2022-12-16 | 2023-01-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-27 | 2022-11-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-27 | 2022-11-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-18 | 2022-09-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-18 | 2022-09-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-18 | 2022-09-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-18 | 2022-09-16 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-08-18 | 2022-09-16 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-08-18 | 2022-09-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-17 | 2022-08-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-17 | 2022-08-10 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-07-17 | 2022-08-10 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-07-17 | 2022-08-10 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2022-07-17 | 2022-08-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-27 | 2022-05-13 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-04-27 | 2022-05-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-28 | 2021-11-14 | 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 | 2021-10-28 | 2021-11-14 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-10-28 | 2021-11-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-10-28 | 2021-11-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-28 | 2021-11-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-28 | 2021-11-14 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-10-28 | 2021-11-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-10-28 | 2021-11-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-28 | 2021-11-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-28 | 2021-11-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-10-28 | 2021-11-12 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-10-28 | 2021-11-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-28 | 2021-11-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-22 | 2021-07-09 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-30 | 2020-01-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-25 | 2019-11-29 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-10-25 | 2019-11-29 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-25 | 2019-11-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-25 | 2019-11-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-25 | 2019-11-29 | 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 | 2019-10-25 | 2019-11-29 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-10-25 | 2019-11-29 | N |
| 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. | Health | 2019-10-25 | 2019-11-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-25 | 2019-11-29 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-10-25 | 2019-11-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-10-25 | 2019-11-29 | N |
| 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. | Health | 2019-10-25 | 2019-11-29 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-10-25 | 2019-11-29 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-10-30 | 2019-11-29 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-10-30 | 2019-11-29 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-10-30 | 2019-11-29 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-10-30 | 2019-11-29 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-10-30 | 2019-11-29 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-10-30 | 2019-11-29 | N |
| Establish methods for sharing information. | Fire Safety | 2019-10-30 | 2019-11-29 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-10-30 | 2019-11-29 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-10-30 | 2019-11-29 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-10-30 | 2019-11-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-10-30 | 2019-11-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-30 | 2019-11-29 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-10-30 | 2019-11-29 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-10-30 | 2019-11-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-30 | 2019-11-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-30 | 2019-11-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-30 | 2019-11-29 | 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 | 2019-10-30 | 2019-11-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-10-30 | 2019-11-15 | N |
