Deficiency Records for St Anthony Health and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for St Anthony Health and Rehabilitation. 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? |
|---|---|---|---|---|
| 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 | 2023-01-20 | 2023-02-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-20 | 2023-02-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-19 | 2023-02-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-19 | 2023-02-24 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-01-13 | 2023-02-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-13 | 2022-07-29 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-07 | 2022-06-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-24 | 2021-10-20 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-05-24 | 2021-06-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-24 | 2021-06-29 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-05-24 | 2021-06-29 | N |
| Provide activities to meet all resident's needs. | Health | 2021-05-24 | 2021-06-29 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-05-24 | 2021-06-29 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-05-24 | 2021-06-29 | 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 | 2021-05-24 | 2021-06-29 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-05-24 | 2021-06-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-24 | 2021-06-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-24 | 2021-06-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-24 | 2021-06-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-24 | 2021-06-29 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-05-24 | 2021-06-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-24 | 2021-06-29 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-24 | 2021-06-29 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-05-24 | 2021-06-29 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-05-24 | 2021-06-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-05-19 | 2021-06-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-19 | 2021-06-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-19 | 2021-06-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-19 | 2021-06-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-19 | 2021-06-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-19 | 2021-06-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-25 | 2019-12-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-25 | 2019-12-04 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-25 | 2019-12-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-25 | 2019-12-04 | 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 | 2019-10-25 | 2019-12-04 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-10-25 | 2019-12-04 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-25 | 2019-12-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-25 | 2019-12-04 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-10-25 | 2019-12-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-25 | 2019-12-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-25 | 2019-12-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-25 | 2019-12-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-25 | 2019-12-04 | 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 | 2019-10-25 | 2019-12-04 | 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 | 2019-10-25 | 2019-12-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-25 | 2019-12-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-10-25 | 2019-12-04 | N |
