A list of the most recent deficiencies for Mary, Queen and Mother 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? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-08 | 2024-02-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-08 | 2024-02-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-08 | 2024-02-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-08 | 2024-02-23 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-01-08 | 2024-02-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-08 | 2024-02-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-08 | 2024-02-23 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-01-08 | 2024-02-23 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-01-08 | 2024-02-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-01-08 | 2024-02-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-08 | 2024-02-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-08 | 2024-02-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-08 | 2024-02-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-08 | 2024-02-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-08 | 2024-02-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-08 | 2024-02-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-08 | 2024-02-23 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-01-08 | 2024-01-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-06 | 2023-01-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-06 | 2023-01-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-18 | 2021-12-03 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-10-18 | 2021-12-03 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-10-18 | 2021-12-03 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-10-18 | 2021-12-03 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-10-18 | 2021-12-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-10-18 | 2021-12-03 | N |
| Respond appropriately to all alleged violations. | Health | 2021-10-18 | 2021-12-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-18 | 2021-12-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-18 | 2021-12-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-18 | 2021-12-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-18 | 2021-12-03 | 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 | 2021-10-18 | 2021-12-03 | 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 | 2021-10-18 | 2021-12-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-10-18 | 2021-12-03 | N |
| Post nurse staffing information every day. | Health | 2021-10-18 | 2021-12-03 | 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 | 2021-10-18 | 2021-12-03 | 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 | 2021-10-18 | 2021-12-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-10-18 | 2021-12-03 | 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 | 2021-10-18 | 2021-12-03 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2021-10-18 | 2021-12-03 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-10-18 | 2021-12-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-18 | 2021-12-03 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2021-10-18 | 2021-12-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-18 | 2021-12-03 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-18 | 2021-12-03 | Y |
| 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 | 2021-10-18 | 2021-12-03 | 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 | 2021-10-18 | 2021-12-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-18 | 2021-12-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-18 | 2021-12-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-10-18 | 2021-12-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-18 | 2021-12-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-18 | 2021-12-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-06-05 | 2019-07-15 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-06-05 | 2019-07-15 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-06-05 | 2019-07-15 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-06-05 | 2019-07-15 | 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 | 2019-06-05 | 2019-07-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-05 | 2019-07-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-05 | 2019-07-15 | 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 | 2019-06-05 | 2019-07-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-05 | 2019-07-15 | 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 | 2019-06-05 | 2019-07-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-06-05 | 2019-07-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-06-05 | 2019-07-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-05 | 2019-07-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-05 | 2019-07-15 | N |
