Deficiency Records for Ascension Standish Hospital and Skilled Nursing Fac
Updated as of April 01, 2024
A list of the most recent deficiencies for Ascension Standish Hospital and Skilled Nursing Fac. 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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-03-06 | 2024-04-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-06 | 2024-04-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-06 | 2024-04-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-06 | 2024-04-03 | N |
| Post nurse staffing information every day. | Health | 2024-03-06 | 2024-04-03 | 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 | 2024-03-06 | 2024-04-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-06 | 2024-04-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-15 | 2023-12-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-22 | 2023-03-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-22 | 2023-03-27 | 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 | 2023-02-22 | 2023-03-27 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-02-22 | 2023-03-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-22 | 2023-03-27 | 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 | 2023-02-22 | 2023-03-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-22 | 2023-03-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-22 | 2023-03-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-21 | 2023-03-20 | 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 | 2021-10-27 | 2021-11-27 | 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 | 2021-10-27 | 2021-11-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-27 | 2021-11-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-27 | 2021-11-27 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-10-27 | 2021-11-27 | 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 | 2021-10-25 | 2021-11-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-25 | 2021-11-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-10-25 | 2021-11-27 | N |
