A list of the most recent deficiencies for Catholic Eldercare On Main. 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 | 2023-11-16 | 2024-01-10 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-11-16 | 2024-01-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-16 | 2024-01-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-16 | 2024-01-10 | 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 | 2023-11-16 | 2024-01-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-16 | 2024-01-10 | 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 | 2023-11-16 | 2024-01-10 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-11-16 | 2024-01-10 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-11-16 | 2024-01-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-11-16 | 2024-01-10 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-11-16 | 2024-01-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-16 | 2024-01-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-16 | 2024-01-10 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-11-16 | 2024-01-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-11-16 | 2024-01-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-16 | 2024-01-10 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-11-16 | 2024-01-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-16 | 2024-01-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-28 | 2023-04-25 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2023-03-28 | 2023-04-25 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-01-26 | 2023-03-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-18 | 2022-09-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-18 | 2022-09-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-18 | 2022-09-19 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-08-18 | 2022-09-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-18 | 2022-09-19 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-18 | 2022-09-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-16 | 2022-09-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-16 | 2022-09-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-16 | 2022-09-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-16 | 2022-09-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-16 | 2022-09-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-16 | 2022-09-19 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-08-16 | 2022-09-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-20 | 2022-05-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-18 | 2022-01-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-18 | 2022-01-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-18 | 2022-01-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-29 | 2021-09-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-29 | 2021-09-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-20 | 2021-07-01 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-05-20 | 2021-07-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-10-08 | 2020-11-24 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2020-10-08 | 2020-11-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-10-08 | 2020-11-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-10-08 | 2020-11-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-08 | 2020-11-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-10-08 | 2020-11-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-10-06 | 2020-11-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-10-06 | 2020-11-13 | N |
