A list of the most recent deficiencies for St Margaret's Daughters Home. 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? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-12 | 2023-12-28 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-10-16 | 2023-12-08 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-10-16 | 2023-12-08 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-10-16 | 2023-12-08 | 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 | 2023-10-16 | 2023-12-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-16 | 2023-12-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-16 | 2023-12-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-16 | 2023-12-08 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-10-12 | 2023-11-26 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-12 | 2023-11-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-12 | 2023-11-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-12 | 2023-11-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-12 | 2023-11-26 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-10-12 | 2023-11-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-12 | 2023-11-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-12 | 2023-11-26 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-10-12 | 2023-11-26 | Y |
| Post nurse staffing information every day. | Health | 2023-10-12 | 2023-11-26 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-10-16 | 2023-11-26 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-10-12 | 2023-11-26 | N |
| Establish methods for sharing information. | Fire Safety | 2023-10-12 | 2023-11-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-12 | 2023-11-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-03 | 2022-12-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-03 | 2022-12-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-03 | 2022-12-18 | 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 | 2022-11-03 | 2022-12-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-11-03 | 2022-12-18 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-03 | 2022-12-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-03 | 2022-11-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-23 | 2022-02-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-23 | 2022-02-01 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-12-23 | 2022-02-01 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-12-22 | 2022-02-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-15 | 2021-11-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-18 | 2021-05-19 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-04-18 | Not Fixed | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-04-18 | Not Fixed | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-18 | Not Fixed | 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 | 2023-04-18 | Not Fixed | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-18 | Not Fixed | Y |
