A list of the most recent deficiencies for Catholic Memorial 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-06-29 | 2022-08-19 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-06-29 | 2022-08-19 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-06-29 | 2022-08-19 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-29 | 2022-08-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-29 | 2022-08-19 | N |
| Respond appropriately to all alleged violations. | Health | 2022-06-29 | 2022-08-19 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2022-06-29 | 2022-08-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-29 | 2022-08-19 | 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 | 2022-06-29 | 2022-08-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-29 | 2022-08-19 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-06-29 | 2022-08-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-29 | 2022-08-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-29 | 2022-08-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-06-29 | 2022-08-19 | N |
| 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 | 2022-06-29 | 2022-08-19 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-06-29 | 2022-08-19 | 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 | 2022-06-29 | 2022-08-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-06-29 | 2022-08-19 | 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 | 2022-06-29 | 2022-08-19 | 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 | 2022-06-29 | 2022-08-19 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-06-29 | 2022-08-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-29 | 2022-08-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-06-29 | 2022-08-19 | N |
| Keep all essential equipment working safely. | Health | 2022-06-29 | 2022-08-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-07 | 2022-07-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-28 | 2022-04-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-28 | 2022-04-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-16 | 2022-01-07 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-10-10 | 2019-11-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-27 | 2019-11-02 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-08-27 | 2019-11-02 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-08-27 | 2019-11-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-27 | 2019-11-02 | 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 | 2019-08-27 | 2019-11-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-27 | 2019-11-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-31 | 2018-08-23 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-07-31 | 2018-08-22 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-07-31 | 2018-08-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-31 | 2018-08-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-31 | 2018-08-22 | N |
| 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 | 2018-07-31 | 2018-08-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-31 | 2018-08-22 | 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 | 2018-07-31 | 2018-08-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-07-31 | 2018-08-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-07-31 | 2018-08-17 | N |
| Respond appropriately to all alleged violations. | Health | 2018-07-31 | 2018-08-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-07-31 | 2018-08-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-07-31 | 2018-08-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-31 | 2018-08-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-07-31 | 2018-08-17 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-07-31 | 2018-08-17 | N |
