Deficiency Records for Mary, Queen and Mother Center
Updated as of May 01, 2021
This is not the most recent data for Mary, Queen and Mother Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2020-07-06 | 2020-08-07 | 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 |
| 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 |
| 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 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-05 | 2019-07-15 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-05-25 | 2018-07-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-05-25 | 2018-07-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-25 | 2018-07-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-25 | 2018-07-09 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-05-25 | 2018-07-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-05-25 | 2018-07-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-05-25 | 2018-07-09 | N |
| Post nurse staffing information every day. | Health | 2018-05-25 | 2018-07-09 | N |
| Keep all essential equipment working safely. | Health | 2018-05-25 | 2018-07-09 | 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 | 2017-05-02 | 2017-06-16 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2017-05-02 | 2017-06-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-05-02 | 2017-06-16 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2017-05-02 | 2017-06-16 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-05-02 | 2017-06-16 | N |
| 1) Protect current or future residents from giving up their Medicaid or Medicare benefits; or 2) follow federal rules for admissions. | Health | 2017-05-02 | 2017-06-16 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-05-02 | 2017-06-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-05-02 | 2017-06-16 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-05-02 | 2017-06-16 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2017-05-02 | 2017-06-16 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-05-02 | 2017-06-16 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-05-02 | 2017-06-16 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-05-02 | 2017-06-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-05-02 | 2017-06-16 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-05-02 | 2017-06-16 | N |
