Deficiency Records for St Marks Living
Updated as of September 01, 2022
This is not the most recent data for St Marks Living. For the most recent information, click here.
A list of the most recent deficiencies for St Marks Living. 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? |
|---|---|---|---|---|
| Assess the resident when there is a significant change in condition | Health | 2022-06-16 | 2022-08-17 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-06-16 | 2022-08-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-14 | 2022-07-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-14 | 2022-07-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-14 | 2022-07-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-14 | 2022-07-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-14 | 2022-07-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-14 | 2022-07-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-14 | 2022-07-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-14 | 2022-07-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-06-16 | 2022-07-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-06-16 | 2022-07-13 | N |
| Provide or obtain dental services for each resident. | Health | 2022-06-16 | 2022-07-13 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-06-16 | 2022-07-13 | 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 | 2022-06-14 | 2022-07-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-14 | 2022-07-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-14 | 2022-06-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-14 | 2022-06-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-10 | 2022-01-28 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-09-30 | 2021-11-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-30 | 2021-11-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-30 | 2021-11-15 | 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 | 2021-09-30 | 2021-11-15 | 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 | 2021-09-30 | 2021-11-15 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-28 | 2021-11-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-28 | 2021-11-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-09-28 | 2021-11-04 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-09-28 | 2021-11-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-28 | 2021-11-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-28 | 2021-11-03 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-09-28 | 2021-11-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-03 | 2021-08-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-11 | 2021-04-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-03-11 | 2021-04-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-12-02 | 2020-12-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-11-02 | 2020-12-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-09-03 | 2020-10-09 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-09-03 | 2020-10-09 | Y |
| Provide or arrange emergency care by a doctor 24 hours a day. | Health | 2020-09-03 | 2020-10-09 | Y |
| 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 | 2020-09-03 | 2020-10-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-08-19 | 2020-09-11 | 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 | 2020-08-19 | 2020-09-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-05 | 2020-01-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-07 | 2020-01-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-07 | 2020-01-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-10-07 | 2020-01-07 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-10-07 | 2020-01-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-07 | 2020-01-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-11-13 | 2019-12-12 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-10-07 | 2019-11-18 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-10-07 | 2019-11-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-07 | 2019-11-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-07 | 2019-11-18 | 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 | 2019-10-07 | 2019-11-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-07 | 2019-11-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-07 | 2019-11-18 | 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 | 2019-10-07 | 2019-11-18 | 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 | 2019-10-07 | 2019-11-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-07 | 2019-11-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-07 | 2019-11-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-07 | 2019-11-18 | Y |
| 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 | 2019-10-07 | 2019-11-18 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-10-07 | 2019-11-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-07 | 2019-11-18 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-10-07 | 2019-11-18 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-10-07 | 2019-11-18 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-10-07 | 2019-11-18 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-10-07 | 2019-11-18 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-10-07 | 2019-11-18 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-10-07 | 2019-11-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-02 | 2019-11-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-02 | 2019-11-11 | N |
