A list of the most recent deficiencies for St Clara's Rehab and Senior Care. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-08 | 2023-02-23 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-06 | 2023-01-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-06 | 2022-12-30 | 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 | 2022-12-06 | 2022-12-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-06 | 2022-12-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-17 | 2022-12-08 | 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 | 2022-11-17 | 2022-12-08 | N |
| Post nurse staffing information every day. | Health | 2022-11-17 | 2022-12-08 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-11-17 | 2022-12-08 | 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 | 2022-11-17 | 2022-12-08 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2022-11-17 | 2022-12-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-28 | 2022-08-11 | 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 | 2022-04-29 | 2022-05-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-17 | 2022-03-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-22 | 2022-01-04 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-11-23 | 2021-12-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-29 | 2021-11-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-29 | 2021-11-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-29 | 2021-11-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-29 | 2021-11-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-29 | 2021-11-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-11-03 | 2021-11-04 | 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 | 2021-11-03 | 2021-11-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-03 | 2021-11-04 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-10-07 | 2021-10-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-07 | 2021-10-25 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-07 | 2021-10-21 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-10-07 | 2021-10-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-08 | 2021-07-29 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-12-04 | 2020-01-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-12-04 | 2020-01-10 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-12-04 | 2020-01-10 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-12-04 | 2020-01-10 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-12-04 | 2020-01-10 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-12-04 | 2020-01-10 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-12-04 | 2020-01-10 | N |
| Establish methods for sharing information. | Fire Safety | 2019-12-04 | 2020-01-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-12-04 | 2020-01-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-12-04 | 2020-01-10 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-12-04 | 2020-01-10 | 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 | 2019-12-04 | 2020-01-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-04 | 2019-12-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-04 | 2019-12-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-04 | 2019-12-23 | N |
