A list of the most recent deficiencies for St Mary Health Care 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-17 | 2023-11-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-17 | 2023-11-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-17 | 2023-11-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-17 | 2023-11-30 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-10-17 | 2023-11-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-17 | 2023-11-30 | N |
| Post nurse staffing information every day. | Health | 2023-10-17 | 2023-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-17 | 2023-11-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-03 | 2022-03-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-03 | 2022-03-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-03 | 2022-03-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-03 | 2022-03-25 | 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 | 2022-03-03 | 2022-03-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-03 | 2022-03-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-03-03 | 2022-03-25 | 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 | 2022-03-03 | 2022-03-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-03 | 2022-03-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-03 | 2022-03-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-03 | 2022-03-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-03 | 2022-03-25 | 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 | 2022-03-03 | 2022-03-25 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2021-10-13 | 2021-11-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-09 | 2021-06-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-09 | 2021-06-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-22 | 2019-10-14 | N |
