Deficiency Records for St Gertrudes Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for St Gertrudes Health and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-13 | 2024-01-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-13 | 2024-01-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-12-13 | 2024-01-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-13 | 2024-01-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-13 | 2024-01-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-12-13 | 2024-01-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-13 | 2024-01-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-13 | 2024-01-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-12-13 | 2024-01-10 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-12-14 | 2024-01-05 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-12-14 | 2024-01-05 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-12-14 | 2024-01-05 | 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 | 2023-12-14 | 2024-01-05 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-12-14 | 2024-01-05 | 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 | 2023-12-14 | 2024-01-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-14 | 2024-01-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-14 | 2024-01-05 | Y |
| 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 | 2023-08-15 | 2023-08-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-05 | 2023-07-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-02 | 2022-11-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-15 | 2022-10-26 | 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 | 2022-09-15 | 2022-10-26 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-09-15 | 2022-10-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-15 | 2022-10-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-15 | 2022-10-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-15 | 2022-10-26 | 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 | 2022-09-15 | 2022-10-26 | 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 | 2022-09-15 | 2022-10-26 | 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 | 2022-09-15 | 2022-10-26 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-15 | 2022-10-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-15 | 2022-10-26 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-15 | 2022-10-26 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-09-15 | 2022-10-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-09-15 | 2022-10-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-13 | 2022-10-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-13 | 2022-10-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-13 | 2022-10-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-13 | 2022-10-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-09-13 | 2022-10-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-13 | 2022-10-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-13 | 2022-10-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-13 | 2022-10-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-13 | 2022-10-26 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-09-13 | 2022-10-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-13 | 2022-10-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-13 | 2022-10-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-13 | 2022-10-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-18 | 2022-04-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-01 | 2021-12-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-10 | 2021-10-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-10 | 2021-10-08 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-07-21 | 2021-09-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-07-21 | 2021-09-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-21 | 2021-09-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-21 | 2021-09-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-22 | 2021-09-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-22 | 2021-09-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-22 | 2021-09-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-21 | 2021-09-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-07-21 | 2021-09-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-21 | 2021-09-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-21 | 2021-09-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-21 | 2021-09-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-21 | 2021-09-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-21 | 2021-09-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-21 | 2021-08-23 | N |
