A list of the most recent deficiencies for St Mary Healthcare Center. 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-10-05 | 2023-09-21 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-21 | 2023-04-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-21 | 2023-04-03 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-03-21 | 2023-03-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-13 | 2023-03-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-13 | 2023-03-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-13 | 2023-03-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-13 | 2023-03-06 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-02-13 | 2023-03-06 | 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 | 2023-02-13 | 2023-03-06 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-02-13 | 2023-03-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-13 | 2023-03-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-07 | 2022-06-24 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-07 | 2022-06-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-24 | 2022-02-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-24 | 2022-02-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-24 | 2022-02-08 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-24 | 2022-02-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-24 | 2022-02-08 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-24 | 2022-02-08 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-10 | 2020-02-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-02-10 | 2020-02-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-10 | 2020-02-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-10 | 2020-02-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-01-23 | 2020-02-07 | 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 | 2020-01-23 | 2020-02-07 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2020-01-23 | 2020-02-07 | 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 | 2020-01-23 | 2020-02-07 | 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 | 2020-01-23 | 2020-02-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-10-22 | 2018-12-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-22 | 2018-12-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-22 | 2018-12-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-23 | 2018-11-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-23 | 2018-11-16 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-10-23 | 2018-11-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-23 | 2018-11-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-10-23 | 2018-11-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-23 | 2018-11-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-23 | 2018-11-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-23 | 2018-11-16 | 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 | 2018-10-23 | 2018-11-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-23 | 2018-11-16 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2018-10-23 | 2018-11-16 | N |
| Post nurse staffing information every day. | Health | 2018-10-23 | 2018-11-16 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-10-23 | 2018-11-16 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-10-23 | 2018-11-16 | 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 | 2018-10-23 | 2018-11-16 | N |
| Provide or obtain dental services for each resident. | Health | 2018-10-23 | 2018-11-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-10-23 | 2018-11-16 | N |
